Correlations Between Community-Level HIV Preexposure Prophylaxis Coverage and Individual-Level Sexual Behaviors among US Men Who Have Sex with Men

Background HIV preexposure prophylaxis (PrEP) has been associated with changes in sexual behavior after PrEP initiation. However, behavioral differences may also emerge among PrEP non-users in communities with high PrEP coverage. Methods We used demographic, behavioral, and sexual network data from ARTnet, a cross-sectional study of US men who have sex with men conducted during 2017-2019. Multivariable regression models with a Bayesian modeling framework in which individuals were nested within their residential geographic areas were used to estimate associations between area-level PrEP coverage and five sexual behavior outcomes (number of total, main, and casual male partners [network degree]; count of one-time partnerships; and consistent condom use in one-time partnerships), controlling for individual PrEP use. Findings PrEP coverage ranged from 10.3% (Philadelphia) to 38.9% (San Francisco). Total degree was highest in Miami (1.35) and lowest in Denver (0.78), while the count of one-time partners was highest in San Francisco (11.7/year) and lowest in Detroit (1.5/year). Adjusting for individual PrEP use and demographics, community PrEP coverage was associated with higher total degree (adjusted incidence rate ratio [aIRR]=1.73; 95% CrI, 0.92-3.44), casual degree (aIRR=2.05; 95% CrI, 0.90-5.07), and count of one-time partnerships (aIRR=1.90; 95% CrI, 0.46-8.54). Without adjustment for individual PrEP use, these associations were amplified. There were weaker associations with main degree (aIRR=1.21; 95% CrI, 0.48-3.20) and consistent condom use in one-time partnerships (aIRR=1.68; 95% CrI, 0.86-3.35). Interpretation Most of the associations between community PrEP coverage and sexual behavior were explained by individual PrEP use. However, there were residual associations after controlling for individual PrEP use, suggesting that PrEP coverage may partially drive community-level changes in sexual behavior.